Introduction
The National Organization of Nurse Practitioners Faculties (NONPF) outlines nine competencies that nurse practitioners (NP) must demonstrate to graduate and become independent licensed practitioners. One such competency states that NPs should effectively use technology and information literacy during patient interactions. This competency encompasses the use of technology in nursing practice for the benefit of patient care and quality improvement. It also emphasizes the need for practitioners to assess education and literacy needs and implement effective interventions.
Due to the complex and dynamic nature of healthcare, many patients find themselves in situations where they are unable to process the information being discussed regarding their own health. The Institute of Medicine (IOM) reports that over 90 million people in the United States struggle to understand basic health care information. Health literacy is defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (Mosley & Taylore, 2017, p.109). Patients who cannot digest information pertaining to their health are more likely to be noncompliant with treatments or medications, have a poor state of health, and experience emotional strain (Loan…., 2017).
This purpose of this paper is to discuss the value of nurse practitioners using reflective practice to improve the health literacy of their patients. A review of the literature regarding health literacy and reflective practice was conducted. During CINAHL and EBSCO database searches the following key words were used: health literacy, role of nurses in health literacy, patient education, reflective practice for nurse practitioners, reflective practice nursing care and John’s Model of reflective practice.
Johns Reflective Practice Model
Christopher Johns (1995) uses Carper’s fundamental ways of knowing as a framework for nursing practice reflection. He encourages nurses to process through their actions and lived experiences in order become more effective and self-aware practitioners. A habit of reflection creates a safe place for NPs to learn from each patient interaction. Then they can better understand who they are, receive feedback from mentors, make needed adjustments, and feel empowered to become better at what they do and how they respond to those they care for.
When confronted with an opportunity to improve patient care or overcome a challenging situation, NPs using Johns’ model will write or talk about their experience. Initially they work to identify what went well and what did not during the patient interaction. Then they ought to consider what they were trying to accomplish and if the goals were ultimately met. They can also evaluate if they used current evidence or past experiences to guide their decisions. Finally, they need to assess the outcome of the interaction and if decide if they could have done anything different. After processing all the information, NPs can then assimilate what they have learned and emerge with a new perspective to use in future interactions.
Johns’ reflective practice model is especially beneficial for NPs to with patients that have a low level of health literacy. Since NPs are proficient in the language of healthcare, they could unknowingly be blind to the needs of patients who have a limited understanding of common medical terminology or the complex health care system process. If NPs find that patients are frustrated, non-compliant, closed-minded, or emotionally upset during a clinic visit, they can use the practice of reflection to gain insight and improve their approach and decision making.
Literature Review
The American Academy of Nursing published a call to action in 2017 urging those in healthcare leadership positions to make health literacy a top priority in their facilities and educational programs (Loan et al., 2018). Therefore, NPs must reflect on their own practice and do the same.
Ballard and Marie (2016) researched the complexity of health literacy in the cancer patient population. In their literature review they found that only 12% of Americans are considered to be competent in terms of health literacy. They also found that low health literacy in cancer patients can negatively affect incidence and mortality rates as well as the patient’s quality of life. They proposed that all patients should be treated as if they will have difficulty synthesizing information related to their health. They relate this universal approach to a nurse’s understanding of universal precautions. They recommend using the teach-back method, plain language, and written materials to foster learning with all patients to ensure proper understanding of information.
Similarly, Wittenberg, Ferrell, Kanter, and Butler (2018) discovered a need to assess the health literacy skills of nurses working with oncology patients. Therefore, they conducted a cross-sectional survey of 74 oncology nurses to further understand each nurse’s challenges and perceptions surrounding health literacy. They found that nurses often times use intuition to gauge patient understanding or they simply ask patients if they understand what has been said. This approach is unproven and often inaccurate. Wittenberg et al (2018) recommend that nurses be taught the signs of low literacy, ask open-ended questions when evaluating understanding, utilize the teach-back method and The Plain Language Planner for Palliative Care to improve health literacy. They also suggest that nurses receive continuing education to help them provide culturally competent care to their patients since language and cultural barriers are a common cause of low health literacy.
Mosely and Taylor (2017) also saw a need for improved nursing student education regarding health literacy. They developed an online descriptive survey of 15 faculty members and 53 former nursing students to assess health literacy understanding and education needs. The data revealed a gap in the ability of participants to be able to adequality assess patient’s health literacy levels. Mosely and Taylor (2017) recommend that nursing students be taught how to use the Newest Vital Sign (NVS) which is a reliable and valid health literacy assessment tool. When the tool cannot be used, nurses need to be taught various behaviors (such as a unwillingness to read materials) that patients with low level literacy will exhibit so that patient education can be adjusted.
Integration into Future Practice
As a NP, I will see a variety of different patients from different cultures and backgrounds. I need to be sensitive to the fact that not all people have an in-depth understanding of common health care language or the system itself. I will take a universal approach to health literacy and assume that each of my patients has a low level of literacy (Ballard & Hill, 2016). Based upon the literature reviewed, I believe that it would be best to implement a health literacy screening tool, such as the NVS, for all my new patients as a way to assess their baseline level of understanding (Mosely & Taylor, 2017). I also see a benefit of using plain language when speaking about procedures, tests, labs, or medications. For example, when I am explaining to a patient that he has hypertension, I should explain that he has high blood pressure and then explain what that means. My patients will also benefit from the development of simple and succinct educational handouts for complex concepts (Ballard & Hill, 2016). I will also utilize the teach-back method for patients when instructing them. This method is directly associated with improved health outcomes and increased patient understanding (Loan et al., 2018). I will first explain the information then ask the patient to repeat to me what he understands. This will identify any areas that need reinforcement. I foresee this approach as being valuable when placing patients on titratable medications or explaining to them a new diagnosis.
Additionally, I must take into account my personal, ethical, and empirical ways of knowing for a truly holistic approach to patient care (Johns, 1995). Therefore, I plan to keep a digital journal on my computer that I may fill out when I find myself in challenging patient situations to develop my critical thinking skills (Raterink, 2016). I will first write a brief paragraph reflecting on the events and variables surrounding a patient interaction. I will then list the possible influencing factors to help me identify possible areas of intervention. Next, I will state what I could have done differently to learn from the experience. If I cannot see a solution, I will then reach out to colleague or search for an evidence-based solution. As Raterink (2016) emphasizes, reflective journaling is a successful means for advanced practice nursing education and critical thinking development.
Conclusion
Patients who receive care tailored to their level of health literacy are empowered to make educated decisions regarding their personal health and treatments (Loan et al., 2018). NPs must be competent in the area of health literacy so that they are able to provide high quality and personalized care with positive patient outcomes. Through the process of reflection, NPs are able to identify areas in their personal practice that need improvement and coach patients toward positive behavioral change. Thus, fulfilling two aspects of the NONPF (2011) competency related to technology and information literacy.